- VA Opioid Treatment Outcomes Vary Significantly among Homeless and Unstably Housed Veterans
To better address the opioid epidemic in Veterans who are unstably housed or homeless, it is necessary to determine where gaps in opioid-related care exist. This study examined a national sample of 59,954 Veterans who accessed VA homeless programs and represented a range of homeless experiences; 6% of this cohort (3,624 Veterans) entered a homeless program with a history of opioid use disorder (OUD). Findings showed that among the subgroup of homeless Veterans with an OUD history, opioid dose prescribing practices and rates of medication for addiction treatment (MAT) and naloxone receipt varied significantly. Less than one-quarter (23%) of Veterans received a prescription for naloxone, with homeless program-level rates of receipt ranging from 19% to 32%. Thirty-eight percent of Veterans received MAT in the year following entry into a VA homeless program, with program-specific rates ranging from 31% to 50%. Rates of high-dose opioid prescribing and concomitant opioid-benzodiazepine prescribing were highest, and rates of MAT and naloxone prescribing were lowest, among those ages 55+. Current treatment gaps indicate the need for universal policy goals to address OUD among Veterans at risk of being homeless – or who are currently or formerly homeless. Implementation strategies are needed to tailor opioid treatment access and dissemination to homeless and similar vulnerable Veteran groups.
Date: August 1, 2019
- Dual use of VA and Medicare Drug Benefits Associated with Potentially Unsafe Medication Prescribing among Veterans
Previous research shows that dual VA-Medicare Part D prescription drug use is a risk factor for potentially unsafe medication (PUM) exposure in Veterans with dementia and opioid users. Thus, this study evaluated the association of dual prescription use through VA and Part D (vs. VA-only use) with the prevalence of PUM exposure in a national cohort of dually-eligible older Veterans. Findings showed that dual use of VA and Part D prescription drug benefits was associated with an almost 2-fold increase in the odds of exposure to any PUM compared with VA-only use and more than 3 times the odds of exposure to severe drug-drug interactions. PUM exposure was lowest among VA-only users, and PUM exposure peaked in Veterans receiving prescriptions in near-equal proportions (50/50) from VA and Part D. To mitigate the potential risks associated with unsafe medication prescribing, policies intended to expand access to non-VA providers must ensure patient information is shared and integrated into routine practice for all patients seeking care across multiple healthcare systems.
Date: July 22, 2019
- Strategies VA Clinicians Use to Structure Difficult Conversations Regarding Opioid Prescribing
This study aimed to identify and describe clinicians’ strategies for managing prescription opioid misuse and aberrant behaviors among patients prescribed long-term opioid therapy (LTOT) for chronic pain. Interview results identified challenges faced by clinicians in navigating conversations about opioid management, stemming from patient dissatisfaction and clinician ambivalence about enacting guideline-recommended changes. To manage difficult conversations, clinicians shared “verbal heuristics” – essentially a pre-packaged response or conversational short-cut – to more quickly and efficiently guide and defuse challenging, emotional conversations. Four varieties of heuristics were identified and include: safety (i.e., “I don’t feel comfortable prescribing for you anymore because you’re using in a way that’s unsafe.”); setting expectations (i.e., “no early refills even for legitimate reasons”); following orders (i.e., “we’re following the rules…and have no choice”), and standardization (i.e., “I do this for all my patients.”).
Date: July 1, 2019
- Increase in Opioid Overdose Deaths among Veterans Attributed to Increased Overdoses from Heroin and Synthetic Opioids
This study examined trends in VA opioid overdose rates and receipt of prescription opioids among Veterans receiving VA care who died from opioid overdose from 2010 through 2016. Findings showed that the overall rate of fatal opioid overdose among Veterans increased from 14.47 per 100,000 person years in 2010 to 21.08 per 100,000 person years in 2016. There was a decline in methadone overdose and no significant change in natural/semisynthetic opioid overdose, however the synthetic opioid overdose rate and heroin overdose rate increased substantially. Among all opioid overdose decedents, prescription opioid receipt within 3 months before death declined from 54% in 2010 to 26% in 2016. Fatal opioid overdose rates among Veterans receiving VA care increased because of increases in heroin and synthetic opioid overdose rates. Risk of overdose from heroin and synthetic opioids may need to be considered separately from risk from prescription opioids, and prevention efforts must broaden beyond Veterans actively receiving opioids.
Date: July 1, 2019
- Opioid Prescribing Safety Initiative Effective in Decreasing Rates of Opioid Prescribing for Older Veterans with Osteoarthritis
Investigators in this study examined national trends in opioid and non-opioid analgesic prescribing before and after implementation of VA’s Opioid Safety Initiative (OSI). Findings showed that before OSI implementation, total analgesic prescriptions showed a steady rise, which abruptly decreased to a flat trajectory after the OSI was implemented. This trend was primarily due to a decrease in opioid prescribing after OSI, as well as a significant modest rise in acetaminophen prescriptions post-OSI. Among Veterans reporting pain, the intensity of pain remained unchanged over the study period. Thus, changes in analgesic prescribing trends were not accompanied by changes in reported pain intensity for older Veterans with osteoarthritis. No changes in non-steroidal anti-inflammatory drug prescribing were observed. Thus, over the period 2012-2016, VA’s successful efforts to reduce opioid prescribing did not result in worsening pain among patients with osteoarthritis.
Date: June 1, 2019
- Substantial Variation in Opioid Prescribing Rates among ED Providers in the Same VA Healthcare Facility
The study team examined the extent to which variation in individual ED physicians’ opioid prescribing was independently associated with long-term opioid use in Veterans. Using VA data, investigators identified Veterans with an index ED visit at any VA facility in 2012 – and who were opioid naïve (without opioid prescriptions in the prior 6 months). Findings showed that there was a three-fold variation in the rates of opioid prescribing by ED physicians within the same VA facility (21% vs. 6%), regardless of patients’ severity of pain or primary diagnosis. The frequency of long-term opioid use was higher among opioid-naïve Veterans treated by high vs. low-quartile ED prescribers, though above the threshold for statistical significance (1.39% vs. 1.26%). Though the increase in long-term opioid use among Veterans treated by the highest-prescribing ED providers was not significant in the overall sample, it was significant among important patient subgroups, including those with back pain, musculoskeletal pain, or depression. High-intensity prescribers were more likely to prescribe opioids across the spectrum of pain intensity, while low-intensity prescribers were less likely to prescribe opioids across the spectrum.
Date: May 29, 2019
- Rural and Western Region Veterans Prescribed More Opioids Than Urban, Other Regions
This study sought to characterize regional variation in opioid prescribing across VA and examine prescribing differences between rural and urban Veterans. Findings showed substantial rural-urban variation in VA opioid prescribing, with rural Veterans receiving over 30% more opioids than their urban counterparts, with most of the difference attributable to long-term use. Utilization was lowest in the Northeast and highest in the West. Mean days’ supply dispensed at initiation was higher for rural veterans (15 vs. 13) and the proportion prescribed an initial 30 days’ supply was 23% for rural vs. 19% for urban Veterans. The prescribing gap between urban and rural Veterans in the South was 33% vs. 13% in the Northeast, and similar in the West and Midwest. Higher rates of opioid prescribing among rural compared to urban Veterans are driven mostly by higher rates of long-term use, indicating a need for interventions to improve access to non-pharmacologic treatment for chronic pain among rural Veterans.
Date: May 21, 2019
- Receipt of Opioid Prescriptions from Both VA and Medicare Associated with Greater Likelihood of Overdose Death
This study assessed the association between dual receipt of opioid prescriptions from VA and Medicare Part D and prescription opioid overdose death among Veterans enrolled in both VA and Part D. Findings showed that receipt of opioid prescriptions from both VA and Part D was associated with 2-3 times greater odds of overdose death than among Veterans receiving opioids from VA or Part D only. Dual users also had a higher cumulative opioid dose over 180 days and average daily opioid dose. Dual enrollees are a vulnerable group of Veterans, emphasizing the importance of care coordination across providers and healthcare systems to increase the safety of opioid prescribing within and outside VA.
Date: March 12, 2019
- Links Between Opioid Use and Suicide
This review describes what is known about the links between suicide and overdoses, with a focus on pathways through opioid use, issues of intent, risk factors, prevention strategies, and unresolved issues. Many factors promote the initiation and persistence of opioid use, but several specific pathways toward vulnerability to overdose and suicide are highlighted. Interventions that address shared causes and risk factors, such as programs to improve the quality of pain care, expanding access to psychotherapy, and increasing access to medication-assisted treatment for opioid use disorders, have the potential to be high-value investments by addressing both problems.
Date: January 3, 2019
- Link between Length of Prescription for Initial Exposure to Opioids and Long-Term Use
This study examined the association between initial opioid exposure and subsequent long-term use in two national VA cohorts from 2011 and 2016. Findings showed a strong relationship between initial opioid exposure and the future likelihood for long-term use. Cumulative days’ supply of prescription opioids emerged as the strongest predictor of long-term opioid use, which occurred in only 2% of Veterans dispensed 7 days’ or less supply, and in 28% of patients dispensed greater than 30 days’ supply. Comparing 2011 and 2016 data, the association between day’s supply and long-term use persisted, even as the overall rate of long-term opioid use decreased. Findings suggest that limiting initial opioid exposure may reduce risk for long-term opioid use. Moreover, examination of early opioid exposure may offer an opportunity to recognize when a patient is in the process of starting long-term opioid use.
Date: November 5, 2018
- Pharmacotherapy for Opioid Use Disorder Highly Variable across VA Residential Substance Abuse Treatment Programs
Pharmacotherapy, including methadone, buprenorphine, and naltrexone, is both efficacious and cost-effective for treating opioid use disorder (OUD), however it is infrequently prescribed in VA. Investigators in this study sought to describe barriers to and facilitators of pharmacotherapy provided to a national cohort of VA patients with OUD in VA residential substance use disorder (SUD) treatment programs in FY2012. Findings showed that implementation of pharmacotherapy for OUD is highly variable across VA residential SUD treatment programs. Across all 97 treatment programs, the average rate of receipt of pharmacotherapy for OUD in FY2012 was 21% and ranged from 0% to 67%. There were 11 programs where 0% of patients received pharmacotherapy for OUD. Barriers included program or provider philosophy against pharmacotherapy and a lack of care coordination with non-residential treatment settings. Facilitators included education for staff and patients and having a prescriber on staff. Intensive educational programs, such as academic detailing, and policy changes such as mandating buprenorphine waiver training for VA providers, may help improve receipt of pharmacotherapy for OUD.
Date: November 1, 2018
- Veterans Receiving Prescriptions Through Both VA and Medicare Are More Likely to Be Taking Opioids and Benzodiazepines
This study sought to assess the association between receiving medications from both VA and Medicare Part D (dual use) and the receipt of overlapping opioid and benzodiazepine prescriptions. Findings showed that receiving prescription medications from both VA and Medicare Part D was associated with a 27% increased risk of overlapping opioids and benzodiazepines – and more than twice the risk of overlapping high-dose opioids with benzodiazepines – compared to receiving prescriptions from VA alone. Receipt of prescriptions from both VA and Medicare also was associated with a greater risk of opioid/benzodiazepine overlap compared to Medicare alone, although the difference was smaller. Receipt of medications from more than one healthcare system is a key risk factor for unsafe prescribing practices, highlighting the need to enhance coordination of care across healthcare systems to optimize the quality and safety of prescribing.
Date: October 9, 2018
- Pain Intensity Following Discontinuation of Long-Term Opioid Therapy Does Not, on Average, Worsen for Patients
This study sought to characterize pain intensity over 12 months following opioid discontinuation. Findings showed that average pain intensity did not significantly worsen in the 12 months after Veterans discontinued opioid therapy; for some patients, pain intensity improved. Mean estimated pain at the time of opioid discontinuation was 4.9 on a scale from 0-10. Changes in pain following discontinuation were characterized by slight but statistically non-significant declines in pain intensity over 12 months post-discontinuation. Veterans in the mild (average pain = 3.9) and moderate (average pain = 6.3) pain categories experienced the greatest pain reductions post-discontinuation. Of this study cohort, 87% of Veterans were diagnosed with chronic musculoskeletal pain, 6% with neuropathic pain, and 11% with headache pain (including migraine). Study findings can aid clinicians during discussions with patients about opioid discontinuation.
Date: June 13, 2018
- Medical Records Flag for Suicide Risk Increases VA Healthcare Visits among Veterans with Substance Use Disorder
VA has identified suicide prevention as a top priority and established policies to include high-risk suicide patient record flags (PRFs) in the electronic medical record to alert providers of patient risk and increase healthcare contacts. This study sought to identify predictors of new PRFs and to describe healthcare use before and after PRF initiation among VA patients who had received a substance use disorder (SUD) diagnosis. Findings showed that consistent with VA policy, 62% of Veterans with new suicide risk flags attended the recommended number of visits in months 1 to 3, with an additional 14% meeting recommended targets in month 1 only. Further, outpatient contacts in mental health and substance use disorder clinics increased 2 and 4 times, respectively, over the three-month follow-up period, with mean contacts in these services exceeding the minimum required one contact per week in month one. ED visits decreased by 45% in the three months following initiation of a PRF. Demographic predictors of PRF initiation included being younger than 35, White, and homeless. Clinical predictors were cocaine, opioid and sedative use disorders, PTSD, psychotic, bipolar, and depressive disorders, and suicide-attempt diagnoses. Suicide risk PRFs in an electronic medical record and subsequent follow-up increased service use for those Veterans with flags initiated.
Date: June 8, 2018
- Then and Now: Medications for Opioid Use Disorder in VA
As the largest provider of substance use disorder treatment in the nation, VA has taken proactive steps to increase access to medications indicated for opioid use disorder (OUD), which is an essential component of evidence-based care. This article examines the history of those medications (methadone, buprenorphine, and injectable naltrexone) within VA, as well as early and ongoing efforts to increase access to and build capacity for the treatment of OUD, which included adding buprenorphine to the VA formulary in 2006, educational and quality improvement initiatives, targeted resources, national policy, and “big data” initiatives. This article also summarizes research on barriers and facilitators to prescribing and medication receipt.
Date: March 29, 2018
- State-based Prescription Drug Monitoring Programs Might Help Increase Opioid Prescribing Safety among Veterans Using VA and Non-VA Healthcare
This study evaluated VA physicians’ perspectives and experiences regarding the use of state-based Prescription Drug Monitoring Programs (PDMPs) to monitor Veterans’ receipt of opioids from non-VA prescribers. Findings showed that VA primary care physicians broadly embraced PDMPs as a tool to monitor Veterans’ receipt of opioids from non-VA sources despite identifying multiple barriers to optimal use. They also identified several key best practices currently used within VA and made suggestions for future improvements that may enhance efforts to ensure safe opioid prescribing. Key barriers included incomplete or unavailable prescribing data, while key facilitators included linking PDMPs with VA’s electronic health record, using templated notes to document PDMP use, and delegating routine PDMP queries to ancillary staff (i.e., nurses or clinical pharmacists). Applying improvements identified in this study may enable VA to serve as a national model for those seeking to enhance PDMP use, thereby improving opioid prescribing safety.
Date: March 8, 2018
- Opioids Do Not Result in Better Pain-Related Function or Pain Intensity Compared to Non-Opioid Drugs in Veterans with Chronic Pain
This randomized trial compared opioid therapy versus non-opioid medication therapy over 12 months for primary care patients with chronic back pain or hip or knee osteoarthritis pain. Findings showed that the use of opioid therapy compared with non-opioid medication therapy did not result in significantly better pain-related function over 12 months. Opioid therapy compared with non-opioid medication therapy resulted in significantly worse pain intensity over 12 months, but the importance of this is unclear because the magnitude was small. Opioids caused significantly more medication-related adverse symptoms than non-opioid medications. Overall, opioids did not demonstrate any advantage over non-opioid medications that could potentially outweigh their greater risk of overdose and other serious harms. Results do not support initiation of opioid therapy for moderate to severe chronic back pain or hip/knee osteoarthritis pain.
Date: March 6, 2018
- Dual Use of VA and Medicare Associated with Substantial Increase in Risk of Potentially Unsafe Opioid Use among Veterans
This study sought to estimate the prevalence and consequences of receiving prescription opioids from both VA and Medicare Part D for all dually-enrolled Veterans who filled a prescription opioid in either system in calendar year 2012. Findings showed that among Veterans dually enrolled in Medicare Part D and VA and receiving prescription opioids in 2012, more than 1 in 8 received opioids from both systems, in many cases concurrently. Compared to VA-only use of opioids, dual use was associated with a 3-fold higher risk of high-dose opioid exposure and more than twice the risk of long-term high-dose opioid exposure. Dual use also was associated with a 60-90% greater risk of these exposures than Part D only use. VA is evolving into a less integrated delivery system with more community care options. As these options increase, the prevalence of poorly coordinated dual-system care (e.g., overlapping opioids and other drug interactions and duplication) also will likely increase.
Date: February 1, 2018
- Declining Rates in VA Prescriptions for Long-Term Opioids
This study sought to characterize the overall prevalence of opioid prescribing in the VA healthcare system from 2010 through 2016 by duration of use. Findings showed that opioid prescribing trends followed similar trajectories in VA and non-VA settings, peaking around 2012 and subsequently declining. The prevalence of VA opioid prescribing was 20.8% in 2010, 21.2% in 2012, and declined annually to 16.1% in 2016. Changes in long-term opioid prescribing accounted for 83% of the decline seen in VA patients. Comparing data from 2010-2011 to data from 2015-2016, declining rates in new long-term use accounted for more than 90% of the decreasing prevalence of long-term opioid use among Veterans, whereas increases in cessation among existing long-term users was less than 10%.
Investigators observed a decrease in overall opioid prevalence between 2012 and 2015 of 16% in VA healthcare settings, compared to 13% reported in non-VA settings. Recent VA opioid initiatives may be preventing patients from initiating long-term use.
Date: January 29, 2018
- Medical Record Alert Associated with Reduced Opioid and Benzodiazepine Co-prescribing
This implementation project evaluated the effectiveness of an advanced medication alert designed to reduce opioid and benzodiazepine co-prescribing among Veterans with high-risk conditions (substance use disorder, sleep apnea, suicide risk, and age =65) at one VA healthcare system (VA Puget Sound). Findings showed that the proportions of patients with concurrent prescriptions decreased significantly post-alert launch among Veterans with substance use (25%), sleep apnea (39%), and suicide risk (62%), with greater decreases at the alert site relative to the comparison site in sleep apnea and suicide-risk cohorts. Significant decreases in benzodiazepine prescribing were observed at the alert site only.
Date: December 28, 2017
- Systematic Review: Patient Outcomes in Dose Reduction or Discontinuation of Long-term Opioid Therapy Suggest Utility of Multimodal Care
Investigators examined the evidence on the effectiveness of strategies to reduce or discontinue long-term opioid therapy (LTOT) prescribed for chronic pain – and the effect of dose reduction or discontinuation on important patient outcomes, including pain severity and pain-related function. Findings showed that there are multiple strategies to reduce or discontinue long-term opioid treatment for chronic pain, however the quality of the evidence for effectiveness was very low. In 3 good-quality trials of behavioral interventions and 11 fair-quality studies of interdisciplinary pain programs, patients received multimodal care that emphasized non-pharmacologic and self-management strategies. Sixteen fair-quality studies reported improvement in pain severity (8/8 studies), function (5/5 studies), and quality of life (3/3 studies) following opioid dose reduction. However, few studies examined the potential risks of opioid dose reduction such as adverse events (i.e., opioid overdose), illicit substance abuse, or suicide.
Date: July 18, 2017
- Higher Risk of Suicidal Ideation and Suicidal Self-Directed Violence following Discontinuation of Long-term Opioid Therapy
The primary objective of this study was to identify predictors of suicidal ideation (SI) and non-fatal suicidal self-directed violence (SSV) following clinician-initiated discontinuation of long-term opioid therapy. Findings showed that a substantial proportion of Veterans with substance use disorder diagnoses and similar matched patients experienced suicidal ideation or suicidal self-directed violence following discontinuation of long-term opioid therapy by their opioid-prescribing clinicians, most of whom represent new onset cases. Approximately 12% of patients in this sample had SSV and/or SI documented in the medical record in the 12 months following discontinuation of opioid therapy: 47 patients had SI only, while 12 had SSV. Half of patients with SSV attempted suicide by overdose, most commonly with benzodiazepines. Mental health diagnoses associated with having SI/SSV included PTSD and psychotic disorders. The majority of patients (75%) were discontinued from opioid therapy due to aberrant behaviors. Healthcare providers should pay special attention to safety when patients are discontinued from long-term opioid therapy, particularly patients with PTSD or psychotic disorders.
Date: July 1, 2017
- Managing Chronic Pain in the Wake of the Opioid Backlash
This JAMA Viewpoint commentary discusses several options for managing pain, as well as the overuse of the term “opioid epidemic.” Authors warn that imperfect treatments do not justify therapeutic distrust, and suggest that there is a broad menu of partially effective treatment options that can maximize the chances of achieving at least partial amelioration of patients’ chronic pain.
Date: June 20, 2017
- Greater Risk of Opioid Prescription Overlap in Veterans Using Medicare Part D–Reimbursed Pharmacies
This study sought to identify trends in dispensed prescriptions for opioids and the frequency of overlapping days’ supply of prescriptions for opioid medications in Veterans dually eligible for VA and Medicare Part D benefits. Findings showed that over the study period, there was an increasing reliance on the use of Part D–reimbursed pharmacies for opioid prescriptions among Veterans. Although opioid overlap appears to be declining within the VA healthcare system, overlap is increasing among opioid prescriptions dispensed from Medicare Part D–reimbursed pharmacies. Predictors for overlap included female gender, Part D enrollment, no VA medication copay, sleep disorders, psychiatric diagnoses, and substance or alcohol abuse. Veterans who were Hispanic, older, and had higher incomes had lower odds of overlap.
Date: May 1, 2017
- Opioid Use among Afghanistan and Iraq War Veterans
This study sought to understand current opioid use in OEF/OIF/OND Veterans who are regular users of VA care and did not have a cancer diagnosis at the time of this study. Findings showed that opioid use among OEF/OIF/OND Veterans is characterized by moderate doses that are used over relatively long periods of time by a minority of Veterans. Approximately 23% of all OEF/OIF/OND Veterans received opioids, with 7-8% receiving them chronically. The prevalence of high-dose opioids, concurrent use of multiple opioids, and use of long-acting opioids was fairly low. Diagnoses of PTSD, major depressive disorder, and tobacco use disorder were strongly associated with chronic opioid use. Back pain also was strongly associated with chronic use. Findings suggest that the use of opioids is less common among OEF/OIF/OND Veterans compared with Veterans as a whole, and provide a strong baseline for evaluating the impact of recently implemented opioid-related policies.
Date: March 25, 2017
- Addressing the Opioid Epidemic: Lessons Learned from VA
This article describes VA’s efforts to address the opioid epidemic, and lessons learned that can inform other healthcare systems planning comprehensive action to reduce the risks associated with opioid therapy.
Date: March 13, 2017
- Discontinuation of Long-Term Opioid Therapy among Veterans is Overwhelmingly Initiated by VA Clinicians
The aim of this study was to compare reasons for discontinuation of long-term opioid therapy (LTOT) between Veterans with and without substance use disorder (SUD) receiving care within the VA healthcare system in the years following release of 2009 and 2010 clinical practice guidelines. Findings showed that the majority of Veterans (85%) discontinued opioid use because their clinician stopped prescribing, rather than the patients deciding to stop. For patients whose clinicians initiated discontinuation, 75% were discontinued due to opioid-related aberrant behaviors (i.e., suspected substance abuse, aberrant urine drug test). Veterans with SUD diagnoses were more likely to discontinue LTOT due to aberrant behaviors, particularly abuse of alcohol or other substances, compared to Veterans without SUD. High proportions of patients received diagnoses for mental health disorders in the year prior to discontinuation of LTOT, including PTSD, anxiety disorders other than PTSD, and depressive disorders (25%). Increasing rates of opioid discontinuation are likely to occur due to policies and programs that encourage close monitoring of Veterans on LTOT for opioid misuse behaviors. Integrating non-opioid pain therapies and SUD treatment into multiple settings such as primary care and specialty SUD care is one possible approach to enhance their care.
Date: March 1, 2017
- VA Pharmacy Use in the First Year of Choice Act
This study sought to describe pharmaceutical use during the first year of the Veterans Choice Program (VCP) and to understand barriers and facilitators for VA pharmacists to dispensing medications under the VCP. Findings showed that a majority of VCP pharmacy spending in the first year was for hepatitis C virus (HCV) medications, which accounted for only 5% of prescriptions but 90% of costs. However, in 2015, VA experienced greater than expected demand for HCV medications, which exceeded available funding, thus some patients obtained medications through the VCP. The impact of HCV medications on the VCP should be short-lived given broadened availability in VA in 2016. Topical eye drops and opioids represented the most commonly dispensed prescriptions: 16% and 9% of all prescriptions, respectively.
Most prescriptions dispensed (93%) were for formulary agents, but substantial efforts were required from VA pharmacists to work with non-VA providers to use formulary drugs. Challenges related to obtaining medications from VA pharmacies through VCP included requiring controlled substance prescriptions to be hand-delivered, a lack of access to lab data required to safely dispense medications, and substantial time required by pharmacists to communicate with non-VA providers. Safe use of opioids, efficient management of non-formulary medications, and unintended new barriers to access created by the VCP must be addressed, in addition to robust ongoing evaluations to identify new cost, quality, and safety concerns.
Date: February 17, 2017
- VA Opioid Safety Initiative Decreases Potentially Risky Opioid Prescriptions among Veterans
This study examined changes associated with Opioid Safety Initiative (OSI) implementation among all adult VA patients who filled outpatient opioid prescriptions from October 2012 through September 2014 in any of 141 VA facilities. Findings showed that during the two-year study period there was a decrease in the number of VA patients receiving risky opioid regimens, with an overall reduction of 16% among Veterans receiving >100 morphine-equivalent milligrams (mEq) daily dosages and 24% among Veterans receiving >200 mEq. There was a 21% reduction in Veterans receiving benzodiazepines concurrently with opioids. Implementation of the OSI dashboard tool was associated with a significant decrease in all three outcomes (>100 mEq, >200 mEq and concurrent opioid/benzodiazepine prescribing). The implementation of the OSI dashboard tool was associated with a significant decrease in risky opioid prescribing across the VA healthcare system, which highlights the possibility of system-wide approaches to address high-risk opioid prescribing. However, a large number of VA patients remained on these regimens at the end of the study period, which emphasizes the challenges of making significant changes in healthcare systems that treat a large population of complex patients.
Date: January 4, 2017
- Safety Risk for Veterans Receiving Overlapping Buprenorphine, Opioid, and Benzodiazepine Prescriptions from VA and Medicare Part D
Ensuring safe buprenorphine prescribing is especially challenging for VA, which treats a substantial number of Veterans with chronic pain and opioid use disorder, as well as an increasing number of patients who receive concurrent care in the private sector (i.e., Medicare Part D). This study identified Veterans dually enrolled in VA and Medicare Part D who filled a buprenorphine prescription in 2012 from either healthcare system and identified the proportion of Veterans with overlapping prescriptions from either system. Findings showed that more than one in four Veterans who received a VA prescription for buprenorphine – and one in five Veterans who received a Medicare prescription for buprenorphine – also received overlapping prescriptions for opioids from a different healthcare system. Among Veterans receiving buprenorphine from VA, 1% received an overlapping benzodiazepine prescription from Medicare, while among those receiving buprenorphine from Medicare, 16% received an overlapping benzodiazepine prescription from VA. Among VA and Part D buprenorphine recipients who had cross-system opioid overlap, 25% and 35%, respectively, had >90 days of overlap. Findings indicate a previously undocumented safety risk for Veterans dually enrolled in VA and Medicare who are receiving prescriptions for buprenorphine and overlapping prescriptions for opioids and/or benzodiazepines.
Date: December 7, 2016
- OEF/OIF/OND Veterans that Currently Smoke More Likely to Receive Opioid Prescription than Non-Smokers
This study sought to determine if smoking status is associated with the receipt of opioids among OEF/OIF/OND Veterans – and to examine important covariates of smoking (i.e., current pain intensity, gender, and mental health diagnoses) and receipt of opioids. Findings showed that compared to non-smokers, OEF/OIF/OND Veterans who were current smokers were more likely to receive an opioid prescription, even after controlling for covariates including: pain intensity, age, gender, service-connection, substance use disorder, mood disorders, and anxiety disorders. Veterans who reported a higher current pain intensity and those with pain diagnoses also were more likely to receive an opioid prescription. Among this young cohort of Veterans (mean age=30 years), more than one-third (34%) reported moderate to severe current pain intensity within +/-30 days of smoking status, with approximately 8% receiving at least one opioid prescription.
Date: September 21, 2016
- Prescription Opioids Associated with Lower Likelihood of Sustained Improvement in Pain among Older Veterans
This study sought to identify patient factors associated with improvements in pain intensity in a national cohort of Veterans 65 years or older with chronic pain. Findings showed that on average, Veterans prescribed an opioid were less likely to demonstrate sustained improvement in pain intensity scores compared to Veterans who were not prescribed opioids. Overall, average relative improvement in pain intensity scores from baseline ranged from 25% to 29%; almost two-thirds of Veterans met criteria for sustained improvement during follow-up. Findings call for further characterization of heterogeneity in pain outcomes in older adults, as well as further analysis of the relationships between prescription opioids and treatment outcomes.
Date: July 1, 2016
- Prescription Opioid Use among Patients with Recent History of Depression Increases Risk of Recurrence
This study examined whether patients in depression remission who were prescribed opioids for non-cancer pain had an increased risk of depression recurrence. Investigators analyzed two patient populations: Veterans treated in the VA healthcare system, and patients treated by a non-profit integrated healthcare system located in Texas. Findings showed that prescription opioid use among patients with a recent history of depression increased the chance of depression recurrence, and this effect was independent of pain diagnoses and pain intensity scores. Patients with remitted depression who were exposed to opioid analgesics at any point during the follow-up period were 77% to 117% more likely to experience a recurrence of depression than those who remained opioid free, after controlling for other factors. Among VA patients with depression remission, those who received opioids during follow-up were younger, had more psychiatric comorbidities, and had more painful conditions and higher pain scores than those who didn’t receive opioids.
Date: April 1, 2016
- Prescription Use of Codeine Associated with Greater Risk of New Onset Depression among Veterans
This study sought to determine whether the hazard of new depression diagnosis differs among VA patients prescribed only codeine, only hydrocodone, or only oxycodone. Findings showed that Veterans prescribed only codeine for 30 days or longer had a 29% increased risk of a new diagnosis of depression compared to Veterans prescribed only hydrocodone for 30 days or longer. Those prescribed only oxycodone for 30 days or longer were not significantly more likely to develop a new depression diagnosis compared to patients prescribed hydrocodone only. Opioid use of 30-90 days was most common among oxycodone users, and opioid use of more than 90 days was most common among hydrocodone users. The distribution of individual comorbid conditions did not significantly differ across the three types of opioids.
Date: March 22, 2016
- Increased Dose of Prescription Opioids Raises Risk of Suicide among Veterans with Chronic Non-Cancer Pain
This study examined the association between prescribed opioid dose and suicide in a national sample of VA patients with a chronic non-cancer pain condition who received opioid therapy. Findings showed that increased dose of opioids was found to be a marker of increased suicide risk, even when relevant demographic and clinical factors were statistically controlled. Type of opioid dosing schedule (i.e., regularly scheduled, as needed, or both) did not significantly affect suicide risk after accounting for other factors. Similar to the U.S. population and other large studies of VA patients, the vast majority of suicides involved firearms (64%), with overdose accounting for 20% of all suicides.
Date: January 5, 2016
- Individual and Facility-Level Factors Associated with Higher Risk of Suicide Attempt among Veterans Receiving Opioid Therapy
This study examined the associations between the receipt of guideline-recommended care for opioid therapy and risk of suicide-related events, assessing associations between individual-level and facility-level delivery of recommended care, and individual-level suicide-related events. Findings showed that within 180 days following opioid prescription, 1.6% of the study population on chronic short-acting opioids and 2.1% of the study population on long-acting opioids experienced suicide-related events. At the individual level, Veterans who received opioid therapy and had medical frailty, drug, alcohol, or mood disorder, and/or traumatic brain injury had a higher risk of suicide-related events. Patients on opioid therapy within VA facilities that ordered more drug screens were associated with a decreased risk of suicide-related events. Patients on long-acting opioid therapy within facilities that provided more follow-up after new prescriptions also were associated with decreased risk of suicide-related events. Patients on long-acting opioid therapy within facilities having higher sedative co-prescription rates had an increased risk of suicide -related events. Among the sub-population of patients with a substance use disorder and a short-acting opioid prescription, the facility rate use of specialty substance use disorder treatment was associated with lower risk of suicide-related events. Encouraging facilities to make more consistent use of drug screening, providing follow-up within four weeks for patients initiating new opioid prescriptions, avoiding sedative co-prescription in combination with long-acting opioids, and engaging patients with substance use disorders in specialty substance use treatment, may help prevent suicide-related events.
Date: July 1, 2015
- Receipt of Opioid Analgesics and Benzodiazepines Associated with Increased Risk of Death Due to Drug Overdose
This study sought to describe the relationship between the receipt of concurrent benzodiazepines and opioid analgesics and death due to drug overdose in patients receiving prescription opioids for acute, chronic, and non-terminal cancer pain. Findings showed that during the study period, 27% of Veterans who received opioid analgesics also received benzodiazepines. Among those receiving opioid analgesics, receipt of benzodiazepines was associated with an increased risk of death due to drug overdose. About half of the overdose deaths occurred when Veterans were concurrently prescribed benzodiazepines and opioids. Patients who were prescribed concurrent opioids and benzodiazepines –and then stopped receiving benzodiazepines had higher rates of overdose than those patients who had only received opioids. Veterans who received benzodiazepines were more likely to be female, middle-aged, white, and to reside in wealthier areas. Veterans who received benzodiazepines were also more likely to have had a recent mental health or substance use disorder-related hospitalization, a diagnosis of a substance use disorder, or a number of psychiatric disorders (i.e., PTSD, depression, anxiety). These findings provide empirical support for the goal of the VA Opioid Safety Initiative (OSI) to reduce unnecessary co-prescribing of opioids and benzodiazepines, for which there had been limited evidence prior to this study.
Date: June 10, 2015
- Gender Differences in Chronic Pain among Veterans
This study examined a) gender differences in trauma, social support, and family conflict among OEF/OIF/OND Veterans with chronic pain, and b) whether these variables were differentially associated with pain severity, functioning, and depressive symptom severity as a function of gender. Findings showed that 69% of Veterans in the study reported experiencing pain for 3 months or longer (67% of men and 71% of women); 75% stated pain had been present for more than one year. The most problematic sites of pain were: back (37%), joint (33%), headache (12%), and neck (9%). Men and women Veterans did not differ significantly in terms of pain severity, pain interference with function, depressive symptom severity, or use of prescription opioids. Relative to men, women Veterans reporting chronic pain evidenced higher rates of childhood interpersonal trauma (51% vs. 34%) and military sexual trauma (54% vs 3%), as well as lower levels of combat exposure. Being married was associated with greater pain-related functional difficulty for women and lower difficulty for men. Combat exposure was associated with pain-related functional difficulty for women but was unrelated for men. Childhood interpersonal trauma was more strongly associated with pain-related functioning among men. Family conflict was associated with greater pain-related functional difficulty and depressive symptoms for men, but was unrelated for women. Thus, gender may be a salient target of investigation when examining development of and/or adaptation to chronic pain, and is an important consideration in tailoring treatment programs to meet the needs of Veterans with chronic pain.
Date: June 1, 2015
- Stepped Care Intervention Benefits Veterans with Chronic Pain
This randomized controlled trial tested the Evaluation of Stepped Care for Chronic Pain (ESCAPE) intervention in primary care settings that included 12 weeks of analgesic treatment (i.e., acetaminophen, topical analgesics, opioids) coupled with pain self-management strategies (i.e., goal setting, positive self-talk), which was followed by 12 weeks of cognitive behavioral therapy. Findings showed that the stepped-care intervention resulted in statistically significant reductions in pain-related disability, pain interference, and pain severity in Veterans with chronic musculoskeletal pain compared to usual care.
Date: March 9, 2015
- VA Primary Care Intervention Decreases High-Dose Opioid Prescription for Veterans with Non-Cancer Pain
In October 2013, VA initiated a nationwide Opioid Safety Initiative (OSI) that includes goals of decreasing high-risk opioid prescribing practices, including prescribing of high-dose opioids. Prior to this national initiative, the Minneapolis VA Health Care System implemented a primary care population-based OSI aimed primarily at reducing high-dose opioid prescribing. This study evaluated the Minneapolis initiative. Findings showed that the number of Veterans prescribed daily high-dose opioids decreased from 342 to 65. Overall, the number of unique pharmacy patients who received at least one opioid prescription within 90 days decreased 14%. The number of Veterans receiving oxycodone SA decreased from 292 to 3 over the study time period. The number of Veterans receiving other long-acting opioids, as well as hydrocodone-acetaminophen, hydromorphone, and oxycodone/acetaminophen also decreased. The proportion of primary care providers who agreed that it was reasonable for the medical center to set a dosage limit was 76% at baseline and 87% at follow-up. The two most commonly endorsed barriers to lowering doses were patients becoming upset (62% baseline and 64% follow-up) and pressure from patient service representatives or the administration (59% baseline and 22% follow-up).
Date: February 3, 2015
- JGIM Supplement Highlights VA’s Partnered Research
In this JGIM Supplement, 12 articles describe partnered research at various stages – from conceptualizing partnered research to examples of findings borne from bi-directional collaborations with investigators and leaders from clinical operations. These articles cover a wide range of topics highly relevant to VA policy and practice, including performance measure implementation on provider motivation, opioid management, suicide prevention, homelessness, medical home models, and communication of adverse events.
Date: November 1, 2014
- Increased Prescribing Rates for Concurrent Sedative Medications among Veterans with PTSD
This is the first national study that sought to characterize polysedative prescribing in Veterans with PTSD. Findings showed that, over time, there was an increase in the use of polysedatives among Veterans with PTSD: from 34% to 37% for two or more sedative classes, and from 10% to 12% for three or more classes. This represents a concerning clinical trend and a relative increase of nearly 25%. The most common combination of sedatives was an opioid plus a benzodiazapine, which were taken concurrently by 16% of Veterans with PTSD. Two other combinations that were used more frequently than expected were opioids plus skeletal muscle relaxants – and benzodiazepines plus atypical antipsychotics. Polysedative use varied across demographic subgroups, with higher rates among women, Veterans residing in rural settings, younger adults, Native Americans, and Whites. Also, benzodiazepine prescribing was markedly elevated among women (44%) compared to men (34%), and was somewhat lower among older adults (31%) compared to younger adults (36%).
Date: December 16, 2013
- Chronic Opioid Therapy Common among Hospitalized Veterans, Associated with Increased Risk of Death and Re-Admission
This study sought to determine the prevalence of prior chronic opioid therapy (COT) among hospitalized medical patients, in addition to examining characteristics associated with inpatients that had previous opioid therapy compared to those with no opioid therapy prior to hospital admission. Findings showed that COT is common among hospitalized Veterans; moreover, occasional and chronic opioid use was associated with increased risk of hospital readmission and COT was associated with increased risk of death. Nearly 1 in 4 hospitalized Veterans had current or recent COT at the time of hospital admission for non-surgical conditions, and nearly half had been prescribed any opioids. Among the Veterans in this study, 26% had received COT in the prior 6 months, and 20% had occasional opioid therapy. Diagnoses more common in Veterans with COT included COPD, complicated diabetes, PTSD, and other mental health disorders.
Date: December 6, 2013
- Opioid Prescribing for Veterans with Chronic Non-Cancer Pain
This study sought to describe patterns of prescription opioid initiation, identify correlates of opioid initiation, and examine correlates of receipt of chronic opioid therapy (COT) among Veterans with persistent non-cancer pain. Findings showed that the initiation of opioid drug therapy is common among Veterans with persistent pain, but most Veterans are not prescribed opioids long-term. During the study year, 35% of Veterans in the sample received an opioid prescription: 30% were prescribed opioids on a short-term basis (<90 days), and 5% received chronic opioid therapy (>90 days). Clinical factors associated with initiating COT include increased pain intensity, nicotine dependence, substance use disorders, and major depression diagnoses. Nearly one-quarter of Veterans prescribed COT also received prescriptions for benzodiazepine medications, which is a concern given that overdose deaths have been linked to the use of multiple sedating medications. Two-thirds of opioid prescriptions resulting in COT were initiated by primary care clinicians. The authors suggest that this supports the development of guidelines geared toward primary care practice. It also supports the provision of interventions and structures in primary care that facilitate proactive planning around opioid use and its monitoring.
Date: February 1, 2013
- Equitable Rates of Pain Assessment among African American and White Veterans
This study sought to determine whether African American Veterans were less likely to be screened for pain than their White counterparts – and to determine the factors associated with differences in screening rates. Findings showed that VA’s mandate for pain screening has resulted in high and relatively equitable rates of pain assessment among both African American and White Veterans. Although rates of pain screening were lower among African Americans compared to Whites (78% vs.82%), this disparity was reduced by half after controlling for prior healthcare use, in which African American Veterans had a greater number of outpatient visits, which was associated with lower rates of pain screening at the index visit. Overall, Veterans were less likely to be screened for pain if they were African American, female, and married; if they had a diagnosis of deficiency anemia; if they had a greater number of outpatient visits; and if they were an established (vs. new) patient. Veterans were more likely to be screened if they had prior diagnoses of chronic joint, neck, or back pain; opioid abuse, anemia, and pulmonary circulation disorders; and if they had a non-opioid analgesic prescription and/or greater number of inpatient admissions in the previous two years.
Date: November 21, 2012
- Mental Health Diagnoses Associated with Opioid Prescription, High-Risk Use, and Adverse Outcomes among OEF/OIF Veterans
Among OEF/OIF Veterans with pain, mental health diagnoses, especially PTSD, were associated with an increased risk of receiving opioids, high-risk opioid use, and adverse clinical outcomes. Compared to those without mental health diagnoses, Veterans with PTSD who were prescribed opioids were more likely to receive higher-dose opioids (16% vs. 23%), receive two or more opioids concurrently (11% vs. 20%), receive sedative hypnotics concurrently (8% vs. 41%), and to obtain early opioid refills (20% vs. 34%). Receiving prescription opioids (vs. not) increased risk for serious adverse clinical outcomes for Veterans (10% vs. 4%) across all mental health categories and was most pronounced in Veterans with PTSD. Of the 141,029 Veterans with pain diagnoses, 15,676 (11%) received prescription opioids for = 20 consecutive days; 77% of which were prescribed by VA primary care providers. Veterans with PTSD and mental health diagnoses excluding PTSD were significantly more likely to receive opioids for pain (18% and 12%) compared to Veterans without mental health diagnoses (7%).
Date: March 7, 2012
- Veterans that Use Cigarette Smoking to Cope with Chronic Pain Experience Worse Pain-Related Outcomes
Veterans who reported smoking as a coping strategy for chronic pain scored significantly worse compared to Veterans who did not smoke and those who denied using cigarettes to cope with pain on the majority of measures of pain-related outcomes. After controlling for demographics and clinical factors, smoking as a coping strategy for pain was significantly and positively associated with pain intensity, pain interference, and fear of pain. There were no significant differences between the three groups on current symptoms of depression or anxiety, indicating that comorbid psychopathology likely did not contribute to poorer pain-related outcomes in the group who used cigarettes to cope with pain. The two smoking groups did not differ with respect to the frequency or severity of nicotine dependence, use of opioid medications, or on other clinical factors, suggesting that impairment in pain-related variables may be due to reliance on cigarettes as a coping strategy for chronic pain.
Date: March 1, 2012
- Majority of OEF/OIF Veterans with Chronic Non-Cancer Pain are Prescribed Opioids by VA Outpatient Providers
This study sought to describe the prevalence of prescription opioid use, types and doses of opioids received, as well as factors associated with the prescription of opioids among OEF/OIF Veterans. Findings showed that about two-thirds of OEF/OIF Veterans with chronic non-cancer pain were prescribed opioids over a one-year timeframe. Of Veterans prescribed any opioids, 59% were prescribed opioids ‘short-term’ compared to 41% prescribed opioids ‘long-term’ (more than 90 days). The mean duration of opioid prescription was 61 days for Veterans in the short-term group and 285 days for Veterans in the long-term group. Several findings suggest a need for improvement in adherence to pain and opioid treatment guidelines. For example, among long-term opioid users, 51% were prescribed short-acting opioids only (guidelines recommend transitioning to long-acting opioids); only 31% were administered one or more urine drug screens (guidelines suggest more frequent drug screening); and 33% were also prescribed sedative-hypnotic medications (monitoring by prescribing physicians is recommended to prevent possible overdose or death). Diagnoses associated with an increased likelihood of receiving an opioid prescription included: low back pain, migraine headache, PTSD, and nicotine use disorder.
Date: September 7, 2011
- Veterans Receiving Higher-Dose Opioid Prescriptions for Pain at Increased Risk of Death from Overdose
This study examined the association of maximum prescribed daily opioid dose and dosing schedule (“as needed,” regularly scheduled, or both) with risk of opioid overdose death among Veterans with cancer, chronic pain, acute pain, and substance use disorders. Findings showed that among Veterans receiving opioid prescriptions for pain, higher opioid doses were associated with increased risk of death from opioid overdose. The frequency of fatal overdose among Veterans treated with opioids was rare – estimated to be 0.04% - and was directly related to the maximum prescribed daily dose of opioid medication. There was no significant increased risk of opioid overdose among Veterans who were treated with both “as-needed” and regularly scheduled opioids – a strategy for treating pain exacerbations – after adjusting for maximum daily dose and patient characteristics. Veterans who died from opioid overdose were significantly more likely to have chronic or acute pain, substance use disorders, and other psychiatric disorders, but they were less likely to have cancer. This study highlights the importance of implementing strategies for reducing opioid overdose among patients being treated for pain, for example, ascertaining history of substance abuse, using treatment contracts, and scheduling frequent follow-up visits and toxicological screens for patients at special risk.
Date: April 6, 2011
- Rates of Accidental Poisoning among VA Patients Higher than General Population
This study describes the rate of accidental poisoning mortality among Veterans who used VA healthcare services, compares this rate to the general U.S. population, and describes the drugs/medications involved. Findings show that for FY05, VA patients had nearly twice the rate of fatal accidental poisoning compared to adults in the general population. Among VA patients who died from accidental poisoning, opioid medications (including methadone) made up 32% of the reported deaths; cocaine also was common at 23%. In both the VA and U.S. general populations, the rate of accidental poisoning mortality was higher for men than women, and higher for individuals ages 30 to 64 as compared to those ages 18 to 29, or ages 65 and older. Although VA patients have a greater risk of suicide than death by accidental poisoning, their risk for accidental poisoning death relative to the general population is larger than that of suicide.
Date: April 1, 2011
- Primary Care-Based Collaborative Care for Chronic Pain May Be More Effective than Usual Care
A primary care-based collaborative care intervention for chronic pain was significantly more effective than usual care across a variety of outcome measures, including pain disability and intensity. However, these improvements were generally modest. Depression severity and pain disability and intensity improved among Veterans in the intervention group who reported both chronic pain and depression. Greater use of adjunctive pain medications and long-term opioids among the intervention group suggested that the intervention contributed to the delivery of guideline-concordant care.
Date: March 25, 2009